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hospital emergencies in a capitalist society

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The Wrath
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Imagine a situation where there has been a terrible car crash, which erupted into a fire. The only survivor will die if he is not given immediate medical care, so he is rushed to the hospital. The doctors don't know if the man has health insurance, and they can't wait for someone to find out because, if they don't start operating immediately, he will die.

How would the hospital deal with this situation in a capitalist society? If it turns out that the man does not have insurance, who pays the bills?

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Well, what would you do if you were a doctor in a hospital where people arrived in that type of emergency condition, and if experience showed you that sometimes, rarely but still possibly, the person later said they could not pay you?

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The doctor should obviously be compensated for his work and expenses. He should be able to garnish the victims wages (if he has no insurance, or cash to pay, or enough credit to borrow the funds from a bank) to recieve payment.

Edited by Scott_Connery
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I think that if uninsured or indigent patients were common (such as in a developing country), there would be medical facilities, and/or branches within a facility that would specialize in low-cost/risky care.

This is sort of what happens in countries like India and China, where there are free government hospitals and exclusive ones for foreigners and the elite that often provider better care than American hospitals. Unfortunately, the quality of the "free" facilities (that leftists love to brag about) is often atrocious.

An Asian-American girl I know once got very sick from food poisoning while traveling in China, and accidentally got sent to one of these facilities because she didn't have her passport with her. Even though she spoke Chinese, no one believed she wasn't a native or even listened to her, and they were about to needlessly remove one of her organs, when one of her friends brought her papers, and she was released. (The private hospital simply her some antibiotics or such and she was fine.)

Edited by GreedyCapitalist
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Do you force him to find a way to pay it or do you just eat the costs?
The cost would almost certainly by borne by the Christian charity that does not want the doc to let folks like that die. If they don't have any such arrangement, the doc can sue. In reality, there really won't be any practical problem.

Legally, the issue is what to assume about a person's wishes if they're not conscious. I figure some "reasonable man" standard would apply. So, if the doctor thinks the guy could use something more than life-saving procedures (say a face-lift), he could not claim that the procedure could not have waited till the patient was conscious. In borderline cases, law might have to be more specific, and juries would have to figure if the doctor made a reasonable assumption.

Edited by softwareNerd
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How would the hospital deal with this situation in a capitalist society? If it turns out that the man does not have insurance, who pays the bills?
Let's focus on the word in Moose's quote which I underlined. The doctor, as an employee of the hospital, gets his money no matter what. The doctor works according to the policies established by the hospital; if the hospital insists on proof of insurance, the triage nurse (well before the doctor) will verify that he has insurance, and if he does not, reject him according to hospital policy (which might simply be a snotty "Go away!!" or a helpful "Take him to Chicago Hope Hospital!"). The hospital's policy is established by its governing board; well, they will follow whatever the concrete policy is regarding possibly uninsured emergency cases, in consideration of the purpose of the particular hospital. In a capitalist society, there will be no law forcing hospitals to accept patients and absorb the cost. At the same time, there will be no law preventing that from happening. And as we know, for literally thousands of years, there have been people who are willing to do what they could to save the lives of people at risk. This is true not just of medicine, but also fire, flood, famine, and various other disasters that befall man. I think the point that once in a while gets lost in discussions of "what if.. under capitalism" is that capitalism works because voluntary cooperation with men is a virtue. What socialism has done, and I think this may be the greatest spiritual evil of socialism, is raise kindness and charity to the level of a moral obligation, an obligation which you may be forced to fulfill.

BTW, garnishing wages is moral only if a person agrees to something; in the context under discussion, the man is incapable of agreeing, so the accident victim has no legal obligation to pay the bill handed to him (and thus certainly there is no basis for using force to deprive him of his wages). It's open for discussion whether he has a moral obligation, given the Trader Principle.

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I had thought of the charity thing, as well, but there will, no doubt, be situations in which a charity does not cover the tab. And if you're talking about charities, you also have to consider non-emergency situations. For instance, if someone has bone cancer, treatment is not an emergency, in that it doesn't have to be done "right now" or the guy will die. There are too many people without insurance for them all to be paid for by charities.

DavidOdden, I agree with your point about human good will, about how we tend to help those we perceive as being in emergencies. But my above point applies to this as well. Why would a doctor be more willing to help out an uninsured victim of a car crash than he is to help out an uninsured cancer patient? I suppose part of the reason might be that he doesn't know whether or not the guy is insured, whereas he will have ample time to find out about the cancer patient. Hospitals cannot afford to just absorb all uninsured cases that come by, so there has to be some standard by which they decide which ones to absorb and which to turn away. I think uninsured smokers, for instance, should be turned away for any smoking-related health problems. Likewise for people injured in car crashes, for which they are clearly at fault.

Note that I do not believe health care is a right. I believe hospitals should be able to turn away anyone they want, for any reason. But I also, as DavidOdden pointed out, recognize that human beings tend towards benevolence to people that they perceive as being in life-or-death situations. I just think this presents a dilemma when it comes to balancing out that benevolent nature with the fact that all uninsured costs cannot be absorbed by hospitals and charities.

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I do work all of the time for which I am paid after the fact. The difference is that, I do have a contract, which really, assists with legal recourse against the unpaying customer. However, I would think there is an assumed contract of some kind...like when you eat at a sit down restaurant.

Even though you might be unconcious when brought in, it would be reasonable for a doctor to believe that being fixed after an accident would be what you would have wanted had you been concious. I don't feel the same aversion to garnishment of wages under those circumstances. If I fall asleep at the wheel and run into a fence, I still have to pay for the fence even though I did not choose to run into it. Damage you do, unintentionally, is still your responsibility to pay for. If you are hurt and someone brings you to the hospital you cost the facility a certain amount of money. If you don't want to be treated when hurt, I think, because it would be such an unusual desire, it would be your responsibility to wear a bracelet stating the fact.

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Good point, although I should point out that falling asleep at the wheel is your fault. And there are bracelets that can be worn, that show that you deny medical care.

At any rate, I tend to agree with you about having wages garnished. If that were not allowed, then everyone who was unconscious at the time of care would wake up and refuse to pay, saying "well, you can't prove that I wanted the medical care."

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Why would a doctor be more willing to help out an uninsured victim of a car crash than he is to help out an uninsured cancer patient?
It's a matter of hospital policy and the fact that he is an employee of the hospital. Did you mean, why would a hospital have a particular policy? There are very many differences and very many possible hospitals in consequence of that, an you listed some of them. We have the difference between being uncertain about unsurance vs. be certain (the unconscious man may not be able to speak clearly enough to say whether he does or does not have insurance; the person diagnosed with cancer and needing treatment probably can give some sign). We also have the "immediate need" vs. "long-term need" issue, i.e. if the crash victim is booted out he will die within the hour, but the cancer patient will die with the year. The issue of "consequences of your actions" distinguishes the two.

Charity is still highly relevant; when you say that there are cases where charity won't cover the tab, you're misunderstanding the nature of charitable policies at hospitals. It's not that a for-profit hospital run by Kaiser Permanente take in any and all charity cases and they goes begging to United Way to pay the bills. There are entire hospitals that have charitable work as their very nature. Basically, if you get whacked by a truck and have no money, get taken to Mercy Hospital, because by policy, they will treat you free if you cannot afford to pay. These hospitals cannot afford to absorb every freeloading jerk who demands that someone else take care of him, and in a capitalist society, I do think there would have to be a period of, shall we say, "readjustment", where the freeloading leeches suck up every penny of medical help and then some, and make it impossible for charitable hospitals to function. Before this happens, charity would be limited to immediate life and death emergencies, just as it is in pits like say Dar Fur.

The notion of an assumed contract isn't applicable in the present case. With a restaurant, you voluntarily enter the restaurant, deliberately and knowingly request food with the implicit promise to pay, and therein lies the source of your obligation to pay. No such contract could possibly exist when you have an unconscious person being brought into a hospital without permission much less a request to be brought there. So no legal obligation to pay arises. It might be reasonable to assume that you would have directly requested help and would have been willing to obligate yourself, had you been conscious, but it is not at all guaranteed (since people have been known to kill themselves). The nature of a contractual obligation is that you have to actually agree, in order to incur the obligation. The hospital may well try to persuade the person that he should pay the bill, but there is no basis for using force to compel the man to shoulder an obligation that he did not agree to. Yes, it's true that everybody who is wheeled in unconscious can say "I won't pay, I didn't agree to this", but I don't think most people are actually that irresponsible.

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The issue of "consequences of your actions" distinguishes the two.

But the consequences are the same. The only difference is the amount of time that it takes. Then again, if a cancer patient has a year to live, I suppose that gives him some time to figure out an alternative way to get the treatment he needs. For what it's worth, I agree that the situations are different, but can't really come up with a good reason why. If I were a doctor, I would feel more concerned for the crash victim than the cancer patient, but can't think of a good reason since, if left untreated, they will both wind up dead.

I do think there would have to be a period of, shall we say, "readjustment", where the freeloading leeches suck up every penny of medical help and then some, and make it impossible for charitable hospitals to function. Before this happens, charity would be limited to immediate life and death emergencies, just as it is in pits like say Dar Fur.
Can you clarifiy this a bit. Why would freeloaders suck up more money at charitable hospitals than they do already?

It might be reasonable to assume that you would have directly requested help and would have been willing to obligate yourself, had you been conscious, but it is not at all guaranteed (since people have been known to kill themselves). The nature of a contractual obligation is that you have to actually agree, in order to incur the obligation. The hospital may well try to persuade the person that he should pay the bill, but there is no basis for using force to compel the man to shoulder an obligation that he did not agree to. Yes, it's true that everybody who is wheeled in unconscious can say "I won't pay, I didn't agree to this", but I don't think most people are actually that irresponsible.

The problem I see with this is that the number of people who falsely claim they would have declined treatment will be far greater than the number who, in actual fact, would have consciously made that decision. No matter which way you go on this one, someone's rights will be violated: either the few patients who really didn't want to be treated or the hospital that has been deprived of its money. In a situation where someone will inevitably get screwed, I think it's only fair to side with the people who have the potential to get screwed more often (i.e. the hospitals).

Edited by Moose
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The notion of an assumed contract isn't applicable in the present case. With a restaurant, you voluntarily enter the restaurant, deliberately and knowingly request food with the implicit promise to pay, and therein lies the source of your obligation to pay. No such contract could possibly exist when you have an unconscious person being brought into a hospital without permission much less a request to be brought there. So no legal obligation to pay arises. It might be reasonable to assume that you would have directly requested help and would have been willing to obligate yourself, had you been conscious, but it is not at all guaranteed (since people have been known to kill themselves). The nature of a contractual obligation is that you have to actually agree, in order to incur the obligation. The hospital may well try to persuade the person that he should pay the bill, but there is no basis for using force to compel the man to shoulder an obligation that he did not agree to. Yes, it's true that everybody who is wheeled in unconscious can say "I won't pay, I didn't agree to this", but I don't think most people are actually that irresponsible.

What about the idea of it being a tort? If youu inadvertently cause damage or cost to someone, you are liable for those costs. Would that not be the case here?

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No matter which way you go on this one, someone's rights will be violated: either the few patients who really didn't want to be treated or the hospital that has been deprived of its money. In a situation where someone will inevitably get screwed, I think it's only fair to side with the people who have the potential to get screwed more often (i.e. the hospitals).

Actually, I am not sure that is true. The rights of the hospital are not viloated so long as they are not required by law to treat uninisured persons. They might choose if there are enough payers to non-payers that it is worth the risk, or they might not. If someone doesn't pay, the hospital would only have itself to blame for treating someone without their being concious. From a rights perspective, it seems that it would be the responsibility of people who did want to be treated to carry something which implied a contract. It sounds terribly cold, but it would probablybe in a hospital's best interest to let someone die out in the street if they had not bracelet. The only upside might be a possible increase in patronage if they benevolently treated people in emergencies without charge but I would be surprised if the benefit would outweigh the cost.

Another possibility would be that a person who delivers them to the hospital(or calls the ambulence) assumes responsibility for the cost. Probably do away with good samaritans for the most part.

Edited by aequalsa
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What about the idea of it being a tort? If youu inadvertently cause damage or cost to someone, you are liable for those costs. Would that not be the case here?

I don't think tort can be a factor, because that assumes responsibility on the part of the person being treated. If someone is hit by a drunk driver, it's not really his fault that he needs medical attention.

Actually, I am not sure that is true. The rights of the hospital are not viloated so long as they are not required by law to treat uninisured persons. They might choose if there are enough payers to non-payers that it is worth the risk, or they might not. If someone doesn't pay, the hospital would only have itself to blame for treating someone without their being concious. From a rights perspective, it seems that it would be the responsibility of people who did want to be treated to carry something which implied a contract. It sounds terribly cold, but it would probablybe in a hospital's best interest to let someone die out in the street if they had not bracelet. The only upside might be a possible increase in patronage if they benevolently treated people in emergencies without charge but I would be surprised if the benefit would outweigh the cost.

I see your point, but I think it could be argued that you violate the hospital's rights by lying about whether or not you would have refused medical care, had you been conscious.

Another possibility would be that a person who delivers them to the hospital(or calls the ambulence) assumes responsibility for the cost. Probably do away with good samaritans for the most part.

I don't know about you, but if I called 911 for someone that I saw lying on the side of the road, I sure as hell wouldn't be willing to pay whatever medical bills may result from the incident.

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I don't think tort can be a factor, because that assumes responsibility on the part of the person being treated. If someone is hit by a drunk driver, it's not really his fault that he needs medical attention.

I had in mind circumstances where no one else was at fault. In that circumstance the drunk driver would be responsible for the cost of your injuries.

I see your point, but I think it could be argued that you violate the hospital's rights by lying about whether or not you would have refused medical care, had you been conscious.
I agree that that would be fraud, although it would probably be a difficult thing to prove.

I don't know about you, but if I called 911 for someone that I saw lying on the side of the road, I sure as hell wouldn't be willing to pay whatever medical bills may result from the incident.

I think my reasoning is sound, but it seems to lead in an uncomfortable direction. Seeing the guy lying in the road, the rational response would be to say "man...bet that hurt" then walk away. Or, I suppose you could bring them in to a hospital but not sign for the person in hopes that private charities there would be willing to pay.

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This is why indentured servitude should be legal. Sure, you have a right to refuse medical care if you don't want it. You have the responsibility on that end-- carry something that says "Do not resuscitate", or pay for your own medical insurance (which would be a LOT cheaper if the guv didn't meddle with medical care), or deal with the possibility you will be stuck with a big ugly bill that may take you years or decades to pay off. That's how it ought to be done, in my opinion.

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From a rights perspective, it seems that it would be the responsibility of people who did want to be treated to carry something which implied a contract. It sounds terribly cold, but it would probablybe in a hospital's best interest to let someone die out in the street if they had not bracelet.

Carrying a 'bracelet' indicating your willingness to pay for what can be deemed 'necessary' medical treatement is exactly the solution to this problem. I say 'bracelet' because this could easily be a card in your wallet, a chip implanted in your skin, or an entry in an online fingerprint database that states your preferences. I say 'necessary' because if there were a dispute, whether or not a specific treatment for a specific person was 'necessary' could be determined through the court system.

Personally, I'd want this system anyway, because it would also allow me to inform the hospital of any medication I was taking, my blood type, any allergies, my closest relatives, and a plethora of other useful information.

In reality, we already partially have this system. If I got hit by a truck today, they'd look in my wallet, find out who I am, and use that to track down my doctor and my relatives. The doctor would have all pertinent medical information. Furthermore, my driver's license says I'm a willing organ donor in case I'm dead anyway and someone needs organs (this is a statewide program that probably exists in most states). Finally, I have my insurance card in my wallet, and the doctor has my insurance records.

Someone could probably make a lot of money by formalizing a system of medical identification or doing an online fingerprint thing, and making it relatively inexpensive. Then there would be no excuse for someone who wasn't on record as being willing to pay for necessary procedures. Only the most destitute people would fall into that category, and as a doctor, while I'd want to save the average accident victim out of 'goodness' (and hope I'd get compensated), I'd probably not feel bad about letting the crackhead, or the ghetto dweller who is simply hoping for a freebie, die - because those people would essentially either be trying to game the system, or they'd legitimately rather die than make the commitment to pay it back (very rarely indeed).

By the way, if I were a doctor and a person with bone cancer came to me for help, I'd ask him to set up a plan of repayment, kind of like a loan (and I think you can get medical loans these days). If the person said they were too poor to afford the procedure that way (i.e. they refused to get a job), I'd tell them they weren't worth the resources it would take to save them.

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What about the idea of it being a tort? If youu inadvertently cause damage or cost to someone, you are liable for those costs. Would that not be the case here?
I don't know if the concept of tort has become twisted in modern law so this is no longer true (I should just buy the Restatement of Torts if this keeps up), but the basic and I would say correct view of tort would not be applicable. If you were to drive your car through your neighbor's house, either because you were drunk or inattentive, or if your car were to roll down the hill into the house because you forgot to turn the wheels or set the brake, that is a tort. This means that you are liable to pay the repairs on the neighbor's house. Applying tort to the accident victim would be analogous to the case where you damage your own house and come person comes in without permission to repair your house, then presenting you a bill. Even if the damage is to yourself, other people cannot claim the right to repair you or your property and thus lay claim to your wealth.
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The scenario of a person being brought to a hospital and who can not pay happens every day. Currently the law requires that in any real life or death emergency, that the hospital do all the treatment without regard to the ability to be paid. No one can be treated unless , 'Permission to Treat' for is signed. In the event the person is a minor or is unconscious. Hospitals have on tap a quick phone call to a local Judge who can issue an order equal to a signed permission to treat from the patient.

In all true emergencies, care must be given without consideration to ability to pay.

Funding for emergency rooms comes from profitable parts of the hospital, raising the rates of the emergency room so the unpaid cases are partially paid for by the paid cases. The Federal and State governments often pay sums of money to hospital emergency rooms.

In southern Texas, hospitals are being forced to close because of the cost of treating illegal immigrants in emergency room.

Our country benefits from having a large group of illegals to pick our fruits and vegetables at a very low cost. The illegals do not have the clout to negotiate a contract with growers that would include health care for themselves and their families.

Our entire country benefits from having lower prices of fruits and vegetables. Are we ethically bound to pay for the health care of this group?

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The original question was about a capitalist society, not about the current situation in the US. The US is a mixed economy. In particular, there is a lot of government intervention in health care, that drive up costs. The immigrants you speak of do buy some type of medical care when they're in Mexico, so it is only government restrictions that disallow them from buying that type of low-cost medical care when they're in the US. In the US, small changes, like changing the rules for emergency rooms, aren't the solution. Many rules are in place to counteract the negative effect of other rules; and, then one needs more rules, and so on.

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An Asian-American girl I know once got very sick from food poisoning while traveling in China, and accidentally got sent to one of these facilities because she didn't have her passport with her. Even though she spoke Chinese, no one believed she wasn't a native or even listened to her, and they were about to needlessly remove one of her organs, when one of her friends brought her papers, and she was released. (The private hospital simply her some antibiotics or such and she was fine.)

That is a terrifying story. Was the care that incompetent or that hasty where they just decided to remove an organ of hers in error? Was this some corrupt and despicable organ stealing scheme? Was that just sarcasm?

Edited by DarkWaters
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Wow, interesting topic everyone! It's been like forever since I last visited here.

Some quick thoughts, more on fundamentals than on the particulars of this discussion. The general rule in tort law is that there is no liability for nonfeasance - that is to say, you are not liable to a third party for failing to give him assistance. The way my torts professor expressed this concept was to hypothesize Dr. Destructo, who happens upon an innocent baby on railroad tracks, as a train is slowly approaching. He breaks out a cigar, pulls up a chair, and waits for the show. The train runs over and kills the baby. Dr. Destructo is not responsible for the harm, and will not be found liable for failing to save the baby. The general rule for a hospital would be the same - not helping someone who is severely or fatally injured does not lead to liability. However, I wouldn't be surprised if there are certain laws/statutes which would impose liability today if a hospital did refuse to help someone. (I should add, parenthetically, that the law in many states has slowly been trying to squeeze in different ways to find liability in what many of us would consider "nonfeasance" situations.)

As for contract law, because the person is unconscious, he is incapable of accepting the offered help, and I don't think a court would find an implied contract here. Implied contracts generally assume a situation where a party manifests their willingness to enter an agreement without saying so explicitly (or making a written contract), such as ordering in a restaurant.

However, there is another branch of law (which I haven't studied extensively) which might allow someone who helped the unconscious, injured person out to recover his costs. That is the law of restitution. The general principle of restitution is that a "person who has been unjustly enriched at the expense of another is required to make restitution". (Restatement of Restitution, Section 1) The basic idea is that in certain situations, if you confer a benefit onto another person, you are entitled to payment even if they never agree to it. The benefit generally must be measurable, and it must not have been made officiously or gratuitously.

A classic example of an officious benefit is a carpenter who comes by your house, and sees that your garage is run down. He quickly gets his tools and begins making repairs on your garage, while you aren't home. You come home, to find him waiting with a bill for his work. He would lose in court, because he officiously conferred a benefit upon you, without your consent. This result makes sense - he has no right to your property unless you voluntarily contract with him in exchange for his services. Interestingly though, a treatise of mine notes that if he was called to work on your neighbor's house, but mistakenly worked on yours, and you knew about it but silently let him do his work, then you would have to pay him for his services.

Now, if we slightly change the example so that a doctor comes upon an injured driver who is unconscious on the side of the road, and the doctor gives him care to save his life, the man today would be liable to the doctor for restitution. The doctor conferred a benefit upon the injured man, and did not do so officiously, because a court would consider it reasonable that a person would want to receive and pay for medical services, where he needs them and is incapable of agreeing to pay for them. (Parenthetically, a pedestrian who attempted to administer such first aid to an unconscious person would probably be considered officious.)

I have to admit that I am somewhat swayed by that reasoning. One of the things I've noticed throughout my studies in law school is that courts often have to decide what a reasonable default rule will be. I certainly think in the case of someone coming to fix your house or wash your car, etc., its unreasonable for the law to impose liability on you, because the person generally could actually talk with you and see if you were interested in contracting. But in the case of someone who is unconscious and seriously injured, I don't think its unreasonable for a doctor to assume that you do want to live, and that if you were conscious you would agree to pay the doctor to fix you.

As an interesting followup on that, even if some of you wouldn't think the man should be found liable to the doctor for his aid while the man is unconscious, what about subsequent recovery, supposing the man accepted further treatment, but didn't explicitly consent to receive the treatment? The law would certainly consider this grounds for restitution (if not an implied contract), but I'm interested in hearing what others have to think/say about this.

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Wow, interesting topic everyone! It's been like forever since I last visited here.

Some quick thoughts,

Wow...thanks for clearing up the defintions for us. I think that I would be ok with restitution in this circumstance. The idea of letting unconcious people who forgot or lost their ID tags die because they couldn't agree to a contract, seemed like a heavy price to pay to protect the rights of a supposedly suicidal person. I can think of moral reasons as to why their rights are not relevent(pursuing death and all). If they are trying to die, probably doesn't matter much what debt they leave behind.

It still bothers me, though, that their rights seem to be violated. The individual watching the work be done is making a concious choice, so that example seems somewhat different. I don't know. This is a tough one.

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